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Monthly Archives: January 2008

I recently had the pleasure of a cordial and eye-opening conversation with a Jehovah’s Witness during our shared flight. I have always been wary of proselytizing and evangelism, despite my appreciation and respect for many faiths. Normally, I choose to ignore those who are very vocal about their religions. The “Do You Know About The Bible” pamphlet he held out to me initially set me on guard, but something compelled me to listen to what he had to say: the necessity for a doctor to listen and understand others, and the drive for a physician to test and examine the reasons and guidelines by which people choose to live. Two years ago, I would not have been so interested or patient, bringing to me the realization of how much I have changed during the first stages of my medical training thus far.

Upon confession of my ignorance of the teachings and principles of Jehovah’s Witnesses, the man was happy to concisely and conversationally explain the main differences between Jehovah’s Witnesses and mainstream Christian faiths (for example, he grew up a Catholic and compared the two). My curiosity led me to the issues regarding Jehovah’s Witnesses and medicine: in accordance with their efforts to live according to the principles of early Christianity, they place upon themselves the requirement to abstain from blood transfusions. “For the life of the flesh is in the blood… No soul of you shall eat blood,” (Leviticus) both literally and figuratively in the transfer of blood from one body to another. Not long ago, I was disturbed that my Pathology curriculum seemed to repeatedly enforce a pathognomonic connection between homosexuality and HIV/AIDS. This notion urged me to explore further the case of Jehovah’s Witnesses. As medical students (or as consumers of medical TV shows), we are most frequently introduced to this group in the ethical case setting in which a Jehovah’s Witness parent declines a life-saving blood transfusion for his or her child, forcing the doctor to make a choice between respecting their faith and providing medical care as they find necessary.

There is much I have yet to learn about medicine and clinical reasoning, and I would not find it prudent or correct for me to judge whether one or the other side is correct. Nonetheless, there are many layers that remain undiscovered by the superficial learner or observer. First, the religious requirements of Jehovah’s Witnesses appears to have spurred the development of bloodless surgery. One medical benefit to this technique is obvious: without the transfusion of blood, there is little or no risk of accidentally transmitting blood-borne diseases such as HIV, hepatitis B, hepatitis C, Chagas, etc. However, the risk of transmitting these diseases is, at this time, exceedingly small, and the slightly greater (but still small) risk lies in transmitting new diseases that are not yet known or identified. Secondly, as the technology of developing blood products advances, the specificity of the requirements of Jehovah’s Witnesses is tested: can Jehovah’s Witnesses be administered Factor VIII without violation of their beliefs? It seems that Jehovah’s Witnesses may not accept whole blood (rarely used), blood cells (red or white), platelets, or plasma, but they may be able to accept fractions of these components or anything that is not a “significant” component. The definition of “significant” is unclear (unless there are more defined specifications that I have yet to find). Their religious principles may allow them to accept these fractions, but they may still have individual moral objections.

Some physicians, seeing the beliefs of Jehovah’s Witnesses and others in black and white terms, may shun treating such patients. Others may treat them with a heavy hand, wielding the staff of Aesculapius like a bludgeon to beat dissenting views into silent acceptance. However, the man I spoke with rightly pointed out that men and women of his faith hold their bodies to be sacred gifts, and they are often much healthier and more conscientious and compliant as patients than others. For this group, there is but this one issue of transferring blood: would it be so difficult to respect this one request? He took out his wallet and showed me the medical directive card with a big “No Blood” symbol on the front.

Upon applying to medical school, perhaps I didn’t fully appreciate the opportunity to continue a lifelong goal: to see and understand men and women of many faiths, nationalities, cultural backgrounds, and beliefs; to walk in their shoes, and to extend my own hand in brotherhood and humanity.

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I used to take praise for being a good listener to heart, but now I realize that there is much more refinement and improvement needed on my part in order to be the best physician I can be. Proper and effective communication is a goal close to my heart: this involves not only getting the right message across, but also making others heard. Some studies have indicated that physicians spend little time listening to patients tell their stories before launching into a focused series of questions [1]. While I might be appreciated as a good listener in the setting of personal relationships, I suspect that I am not in the clinical setting. In the latter, I worry that I may fall prey to the same instinctual habits to which many trained physicians might be susceptible: listening only to what one wants to hear to make a convenient diagnosis, and focusing too much on conveying a message.

The second year preceptor program has exposed to me the deficits I need to correct while demonstrating to me the importance of detecting subtleties in speech and complexities in the physician-patient interaction. During our sessions in the clinic, I have been surprised by what I did not hear. On a few occasions, my fellow students have mentioned details of the patient’s history, whether subconsciously imagined or truthfully heard, that I did not pick up on. More importantly, there have been situations where what the patient did not say was most important. On one occasion, the patient was previously asked not to give away his diagnosis too readily, so though he was content to answer questions, he resisted divulging more information than was needed to answer each question in the simplest manner. Though this arrangement was artificial, it is not uncommon or outlandish: the openness of approach of each patient to his or her interviewers varies greatly. As we proceeded to ask questions, a case for a gastrointestinal infection seemed to present itself neatly to our medical student minds that lacked exposure to gastrointestinal pathology coursework. Half an hour before, our preceptor, a general internist and Infectious Diseases specialist, guided us through the process of taking a more detailed past medical history, family history, and social history. As I looked at my notebook, I noticed that none of us had asked our patient about his sexual history or any previous diagnoses of sexually-transmitted diseases. I thought to ask him on the basis of completeness, but I decided not to since the case, to me at the time, did not warrant what some might perceive as an invasion of privacy. Instead of concern for completeness, however, I should have considered, “What is the patient not saying that can change the framework of his case and thus his diagnosis?” After interviewing the patient, our preceptor revealed to us that the patient was HIV-positive, and that his symptoms were a result of HIV-associated nephropathy. While we had no previous knowledge of this complication of HIV infection, I was very humbled by the awareness of my lack of acute perception of the empty spaces in the patient’s case that held all of the answers.

Though less of a problem at this time, I am concerned that as a practicing physician I may focus too much on sending a message to my patients in lieu of truly listening to them. This, I believe, is an even greater problem than the first as this one is more insidious in development and may not be a habit corrected as quickly or easily. I am an individual who pursues missions and champions causes, and it has always been within my power to convince and inspire through reason as well as passion. However, when presented with great numbers of the afflicted or affected, it becomes easy to be impatient and formulaic in approach with the individual. When it becomes harder to remember the names of patients and their individual stories, my mind may develop archetypes and patterns to explain their behavior, discounting idiosyncrasies and personal feelings and motivations. In doing so, again, I would only be listening to what I want to hear to make my case. Knowing this, patients may tell me, and other physicians, only what we want to hear, keeping silent potentially important details that might hold the key to successful improvements in health.

Listening to another person requires the assigning and acknowledgement of value to the words and thoughts of the other person. As physicians, this task may be more difficult to achieve than we might initially suspect: our colleagues and mentors advise us to take the words of our patients with a grain of salt and to always second guess the reliability of information conveyed by our patients. However, physicians and patients must always remain equal partners in the pursuit of improved health, and the first step toward this aim in our medical culture is the empowerment of patients by bringing them into the discussion on level terms with the physician.

References:

1. Langewitz et al. (2002) “Spontaneous talking time at start of conversation in outpatient clinic: cohort study.” BMJ 325(7366): 682-683.

No critic can confidently state that the life of a physician is an easy one. While some might quietly grumble at the seeming excesses in salary and presumptions of self-importance characterizing many physicians, it is well known that the training of physicians is a long, arduous, and expensive process to he or she who suffers the journey and transformation. The considerable starting capital required, despite a needlessly complicated system of need-blind loans and scant scholarship funds, serves its purpose to limit the size of the physician population to a manageable number. This financial cost, along with the cost of time and great effort, furthermore introduce an undesirable factor by all accounts: a psychological challenge issued to the student, spurring the emergence of a tendency toward victimhood or the humble devotion to a life of service, a culture of exclusive self-interest incompatible with a professional mission of benevolence.

A transformation is inevitable. During four years of medical school and many more years of graduate level training as interns, residents, and fellows, the next generation of physicians is circuitously exposed to varying degrees of emotional and psychological trauma – shocks to the old system in order to encourage new, unfettered growth like controlled fires staving off the threat of environmental catastrophe. Our nights with the dead, our frustrations with the living, and our growing awareness of the broken wills of our predecessors seem to paint a ghastly backdrop for our future careers. The shared moments of excitement and admiration of parents, teachers, and friends are now outnumbered by sobering expressions of concern. It is not difficult to see how students of medicine, burdened and discouraged, might fall prey to a self-image as a victim. It makes us impatient, intolerant, and demanding. Whether leading to sighing resignation, bristling indignity, or utmost attention to profit, the response is essentially the same: all express defeat to circumstance and the shaping hands of external forces.

It is sometimes with regret that we, as civilians and recipients of medical care, express admiration for truly great physicians: men and women of exceptional quality of character (quality of skill often assumed), seemingly so few in number. It is often with little hesitation that we, as physicians or students, see ourselves as better than the majority of other physicians, nurses, and therapists: we consider ourselves the exceptions. Instead of presenting a unified front, we obliquely criticize our nameless and distant colleagues when challenged with the slightest apprehension from patients. Upon my entry into the long training process, I looked with hope upon physicians as a professional group united by a pact of core principles. Though as a relatively new student of medicine I am comforted by shared similarities with my classmates, the gradually increasing differences in character and motivations impress upon me a great divide in the culture of our profession. In some cases, faults of character predate the training process (a penchant for irritability, or perhaps a display of dishonesty in a setting so simple as sharing limited supplies) and are easy to hide from the processes that screen for deviation. However, these pale in comparison to the faults espoused by a defeatist attitude, if only in the number affected and displaying these qualities. In viewing our conditions as unfair and our only brave approach as brazenly entrepreneurial, we allow ourselves to find a station in a baser vision of humanity and human nature at the expense of our dignity, and more importantly, the qualities that define us as physicians.

What makes physicians any different from any other individual? Physicians are not better people: we have self-interest, we make mistakes, and we begin no less flawed than any other. However, we cherish certain qualities in great physicians: they put on display the better parts of humanity, including charity and unconditional love of one’s fellow man. They are intelligent, dignified, and consistent in their devotion and demeanor. They are leaders in the hospital and clinic as well as in the community. They encourage us and inspire us to try harder to care for ourselves, and in doing so, celebrate life in ways that only those who dedicate their lives to medicine can. Those aforementioned burdens, financial and otherwise, are only undesirable in that the favored result is clear: the medical profession, as a whole, has not risen to the challenge of defending itself in a manner that keeps its dignity and core principles intact. The mass movement toward “lifestyle specialities,” the perspective of some senior physicians of current students and young physicians as selfish and fussy, and an emerging demand for better financial education for physicians (in the spirit of “defensive driving”) attest to this failure. Why doesn’t our professional culture succeed in inspiring, reinforcing, and rewarding these qualities of great physicians in each of us?

In truth, the caliber of character of many physicians drives them beyond the goal of excellence to devotion to a profession of service. However, the efforts are centered around the individual, unresponsive to unfocused efforts to mold each new generation of physicians. The call for “professionalism” is a weak cousin to the call to duty of the armed services. Unlike men and women of faith, we do not speak enough of our responsibilities as a “service” to others. Though we may save and protect lives not unlike men and women serving in the police and fire forces, we do not uniformly feel a sense of civic duty. We are not a “band of brothers,” and we are not driven to honorable conduct for the sake of honor. The language surrounding the profession does not speak to these sentiments or any meaningful notion of unity. Medicine in the 20th century was, in many ways, an aristocracy: seemingly invulnerable to loss of status and esteem upon the achievement of degree, regardless of performance and minor deviations in conduct. Now, ever scrutinized under the public’s watchful eye, burdened by profiteering bureaucracy, and disarmed by those who would encroach upon the formerly sacrosanct patient-doctor relationship, physicians have no unifying words or rallying cry from which to draw strength. Our code, the Hippocratic Oath, is more a contract than a mission statement: at this time, it serves to bind us rather than commit us to service. In a field that has facilitated and celebrated the freedom and autonomy of the individual physician, we are now vulnerable in our disunity. We are splintered, fragmented, and untrusting of our fellow physicians.

While some may wish to buttress their positions and wait out what they may hope will wash over and dissipate in time, there is no honor or respect earned in fear. The American medical community has changed in character and manner immensely from century to century, and there is no rule stating that the 21st century must see the continuation of flawed systems and bad habits. The internal culture of the medical profession must change in order to address the needs of a new century. In times to come, if ever we wish to lead our communities, we must learn to temper our internal squabbles and tendencies toward forming factions. On my part, my first effort in this direction is to systematically attend interest group meetings for as many specialties in medicine as I can find – to understand the motivations and perspectives of my colleagues. As it becomes ever more difficult for individual physicians to practice alone, we must learn to view our colleagues as equals, regardless of field. Despite differences in experience and “rank,” we are part of a larger community, one unified by a commitment and something else. To what will we commit? Medicine? The well-being of our patients? Excellence? What will that additional something be? Honor? Duty? Benevolence? Instead of trapping ourselves in an unsolveable puzzle simultaneously requiring humility, a drive for excellence, and perhaps a guilt-ridden or brash sense of pride in the face of adversity, it may help to unite around a central commitment: the service of others. In devoting oneself to the service of others, it is not possible to be too proud of one’s work or ability. In wearing one’s commitment on one’s sleeve, one is not as easily scorned for working merely in self-interest and for profit. In taking the responsibility to lead our communities, we may shed a culture of ineffectuality, self-interest, and victimhood in exchange for a culture fostering strength, capability, and benevolence. The circumstances may not change to suit us. But we can.

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